Patient-Centered Guidelines for Geriatric Diabetes Care: Potential Missed Opportunities to Avoid Harm

Ellen M. McCreedy, PhD; Robert L. Kane, MD; Sarah E. Gollust, PhD; Nathan D. Shippee, PhD; Kirby D. Clark, MD

Disclosures

J Am Board Fam Med. 2018;31(2):178-180. 

In This Article

Results

A total of 366 clinicians comprised the analytic sample. We excluded 30 surveys (8% of respondents) from the analytic sample because their self-reported specialty was "other" or not provided (n = 11), geriatric or palliative care (n = 9), or endocrinology or nephrology (n = 10). Although complete denominator information was not available, we estimated the response rates to be around 8% to 10% for respondents identified using licensure lists, 20% to 25% for those in the PBRNs, and >80% for the participants attending a local professional conference. Data were collected between August and December 2015.

Respondent characteristics for the 73 IM physicians, 108 FM physicians, and 155 NPs are provided in Table 2. Respondents completed their professional education (medical school for physicians) between 1955 and 2015 (median, 1996). IM physicians had, on average, 10 more years since finishing their education (median, 1986). NPs had fewer years since completing their professional education (median, 2003). Clinicians reported a mean duration of a routine visit at 23 minutes (range, 5–90 minutes). The mean duration of a routine visit was similar across clinician types. When asked to estimate the percentage of their practice comprising Medicare patients, 28% of sample reported <25% of their practice was Medicare patients, 20% reported >75% of their practice is Medicare, and most respondents (52%) had practices with between 25% and 75% Medicare patients. NPs were the most likely to report having >75% of their patient population enrolled in Medicare, followed by IM and FM physicians. Of the sample, 52% practiced in Florida, 25% practiced in Minnesota, and 23% practiced in other states (predominately Wisconsin and Colorado). FM physicians were mostly likely to practice in Minnesota. NPs were most likely to practice in Florida. Most of the sample (76%) was obtained using licensure lists from Minnesota and Florida.

Effect of Patient Characteristics on the Decision to Intensify Treatment

Figure 1 presents unadjusted rates of treatment intensification by vignette characteristics at the 2 HbA1c levels considered in this vignette study (7.5% and 8.5%). An 80-year-old with long-standing diabetes was significantly more likely to have her treatment intensified than a 65-year-old with a short diabetes duration at both HbA1c levels (P < .01). At an HbA1c of 7.5%, the 80-year-old had her treatment intensified 39% of the time compared with 70% of the time for the 65-year-old. Hypothetical patients with cognitive impairment that affected IADLs were also significantly less likely to have their treatment intensified at both HbA1c levels compared with hypothetical patients without cognitive impairment. In vignettes, at an HbA1c of 7.5%, the patients with cognitive impairment had their treatment intensified 51% of the time compared with 61% of the time for patients without cognitive impairment (P < .05). Having a history of heart disease with previous coronary artery bypass graft did not affect the decision to intensify treatment at an HbA1c of 7.5%. At an HbA1c of 8.5%, patients with a history of heart disease were more likely to have their treatment intensified than those without a history of heart disease in the vignettes (89% vs 82%, respectively; P < .05).

Figure 1.

Unadjusted rates of treatment intensification by vignette characteristics at 2 glycohemoglobin levels. *P < .05; **P < .01. CABG, coronary artery bypass graft; HbA1c, glycohemoglobin; IADL, instrumental activities of daily living.

The effects of patient characteristics in the vignette on the decision to intensify treatment were similar in the adjusted models. Using random effects probit regression (Table 3, model 1), we found that having a higher HbA1c (8.5% vs 7.5%) increased the probability of treatment intensification by 32 percentage points. Being 80 years old decreased the probability of treatment intensification by 21 percentage points compared with being 65 years old. Having cognitive impairment decreased the probability of treatment intensification by 11 percentage points. Coronary artery disease was not significantly associated with the probability of intensification in the full model (P = .11).

Effect of Clinician Characteristics on the Decision to Intensify Treatment

Most clinician characteristics we specifically measured in the survey were not related to the decision to intensify treatment (Table 3, model 2). Having a longer than average visit duration, a predominately Medicare patient population, or recent completion of professional education (within the past 5 years) did not significantly affect the decision to intensify treatment. However, we did observe differences in intensification by clinician type. FM physicians were significantly less likely than IM physicians or NPs to intensify medication therapy in geriatric patients. NPs were 14 percentage points more likely to intensify therapy than FM physicians; IM physicians were 11 percentage points more likely to intensify therapy than FM physicians (P < .01).

Some of this variation in intensification by clinician type may be better explained by geographic differences in practice patterns (Table 3, model 3). Over half of respondents to this survey and almost 75% of the NPs in the study practice in Florida. Practicing in Florida, compared with practicing in Minnesota or another state, increased the probability of treatment intensification by 14 percentage points (P < .01). After accounting for geographic differences in practice patterns, NPs were 7 percentage points more likely to intensify therapy than FM physicians; IM physicians were 8 percentage points more likely to intensify therapy than FM physicians (P < .05). Adding the source of the survey population (licensure vs PBRN or conference) was not significant once Florida was added to the model (results not shown). The interclass correlation reveals 59% of the variation (95% confidence interval [CI], 49–68%) in the decision to intensify medication therapy was due to unmeasured clinician characteristics.

Treatment Intensification for the Healthiest and Most Complex Hypothetical Patients

Figure 2 shows the predicted probability of treatment intensification for the healthiest and most complex hypothetical patients in the study at 2 HbA1c levels. A 65-year-old woman with a short diabetes duration and no heart disease or cognitive impairment had a mean predicted probability of treatment intensification of 73% (95% CI, 67–78%) at an HbA1c of 7.5%, and probability of 95% (95% CI, 93–97%) at an HbA1c of 8.5%. An 80-year-old woman with long-standing diabetes, coronary artery disease, and cognitive impairment with associated IADL impairment had a mean predicted probability of treatment intensification of 35% (95% CI, 29–41%) at an HbA1c of 7.5% and of 75% (95% CI, 70–80%) at an HbA1c of 8.5%.

Figure 2.

Predicted probability of treatment intensification for the healthiest and most complex cases presented in the vignettes, overall and at 2 glycohemoglobin levels. The graph shows the predicted probability of treatment intensification for a 65-year-old with short disease duration, no cognitive impairment, and no heart disease (healthiest vignette patient) compared with that for an 80-year-old with long-standing diabetes, cognitive impairment with impaired instrumental activities of daily living, and heart disease with previous bypass graft (most complex vignette). Marginal effects were estimated holding physician-level factors (longer than average visit length, ≥75% of practice comprising Medicare patients, completed education in the past 5 years, clinician type, and state where the physician practices). HbA1c, glycohemoglobin.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....